Sint Nicolaasga, Netherlands
Sint Nicolaasga, Netherlands

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Van Den Bemt B.J.F.,Sint Maartenskliniek
Expert Review of Clinical Immunology | Year: 2012

Adherence to medication in patients with rheumatoid arthritis is low, varying from 30 to 80%. Improving adherence to therapy could therefore dramatically improve the efficacy of drug therapy. Although indicators for suboptimal adherence can be useful to identify nonadherent patients, and could function as targets for adherence-improving interventions, no indicators are yet found to be consistently and strongly related to nonadherence. Despite this, nonadherence behavior could conceptually be categorized into two subtypes: unintentional (due to forgetfulness, regimen complexity or physical problems) and intentional (based on the patients decision to take no/less medication). In case of intentional nonadherence, patients seem to make a benefit-risk analysis weighing the perceived risks of the treatment against the perceived benefits. This weighing process may be influenced by the patients beliefs about medication, the patients self-efficacy and the patients knowledge of the disease. This implicates that besides tackling practical barriers, clinicians should be sensitive to patients personal beliefs that may impact medication adherence. © 2012 Expert Reviews Ltd.

Van Der Maas A.,Sint Maartenskliniek | Kievit W.,Radboud University Nijmegen | Van Den Hoogen F.H.J.,Sint Maartenskliniek | Van Riel P.L.,Radboud University Nijmegen | Den Broeder A.A.,Sint Maartenskliniek
Annals of the Rheumatic Diseases | Year: 2012

Down-titration, or discontinuing infliximab, has proven to be feasible in RA patients. Therefore, our local treatment protocol includes tapering infliximab dose. This observational study describes the prevalence of successful down-titration in daily clinical practice and its effect on costs and quality of life (QoL). Methods: Infliximab was down-titrated with 25% of the original dose (3 mg/kg) every 8-12 weeks without interval change until discontinuation or flare in all RA patients with stable low 28-joint disease activity score (DAS28) and stable treatment for >6 months. During 1 year DAS28, RA medication, outpatient clinic visits, RA related absenteeism and EuroQoL5D (European QoL questionnaire, EQ5D) were documented. Prevalence of successful down-titration and changes in DAS28, QoL and costs were described. Results: In 16% (95% CI 6 to 26) and 45% (95% CI 31 to 59), respectively, infliximab could be discontinued or down-titrated. Mean infliximab dose decreased significantly from 224 mg (95% CI 212 to 236 mg) at start, to 130 mg (95% CI 105 to 154 mg) after 1 year. Median DAS28 increased from 2.5 (p25-75=2.0-2.9) to 2.8 (2.2-3.6) (p=0.002). Extra corticosteroids were given in 8% of the visits. Disease modifying antirheumatic drugs were seldom changed. There was no statistical difference in QoL after down-titration. Mean reduction in the costs was €3474 (95% CI 2457 to 4492) per patient. Conclusion: In the majority of patients with stable low DAS28 and stable treatment, infliximab can be down-titrated or discontinued, which results in a considerable reduction in costs without influencing QoL.

Hannink G.,Radboud University Nijmegen | van Tienen T.G.,Sint Maartenskliniek | Schouten A.J.,University of Groningen | Buma P.,Radboud University Nijmegen
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2011

Purpose: To evaluate the long-term effects of implantation of a biodegradable polymer meniscus implant on articular cartilage degeneration and compare this to articular cartilage degeneration after meniscectomy. Methods: Porous polymer polycaprolacton-based polyurethane meniscus implants were implanted for 6 or 24 months in the lateral compartment of Beagle dog knees. Contralateral knees were meniscectomized, or left intact and served as controls. Articular cartilage degeneration was evaluated in detail using India ink staining, routine histology, immunochemistry for denatured (Col2-3/4M) and cleaved (Col2-3/4Cshort) type II collagen, Mankin's grading system, and cartilage thickness measurements. Results: Histologically, fibrillation and substantial immunohistochemical staining for both denatured and cleaved type II collagen were found in all three treatment groups. The cartilage of the three groups showed identical degradation patterns. In the 24 months implant group, degradation appeared to be more severe when compared to the 6 months implant group and meniscectomy group. Significantly more cartilage damage (India ink staining, Mankin's grading system, and cartilage thickness measurements) was found in the 24 months implant group compared to the 6 months implant group and meniscectomy group. Conclusion: Degradation of the cartilage matrix was the result of both mechanical overloading as well as localized cell-mediated degradation. The degeneration patterns were highly variable between animals. Clinical application of a porous polymer implant for total meniscus replacement is not supported by this study. © 2010 The Author(s).

Vriezekolk J.E.,Sint Maartenskliniek | Van Lankveld W.G.J.M.,Sint Maartenskliniek | Geenen R.,University Utrecht | Van Den Ende C.H.M.,Sint Maartenskliniek
Annals of the Rheumatic Diseases | Year: 2011

Objective: To examine the longitudinal association between coping and psychological distress in rheumatoid arthritis (RA). Methods: Bibliographic databases up to July 2010 were searched for longitudinal studies with a follow-up of ≥6 months. Two reviewers assessed the methodological quality of the included studies. Study characteristics, coping strategies and coping-psychological distress associations were extracted. Coping strategies were categorised using a hierarchical taxonomy. A best-evidence synthesis determined the level of evidence for a prognostic association of coping with depression, anxiety and general distress. Results: From an initial set of 2605 potentially relevant studies, 19 studies (14 cohorts) met the predefined selection criteria. In all, 10 studies were of 'high quality' (≥12 of 18 quality criteria). Unadjusted bivariate correlations showed that baseline approach-oriented coping correlated with lower psychological distress (r between 0.007-0.46, p values <0.05) and baseline avoidant-oriented coping correlated with higher psychological distress (r between 0.29-0.64, p values <0.05) at follow-up. Adjusted for baseline psychological distress, limited evidence was found that avoidant-oriented coping was longitudinally associated with an increase in psychological distress. Specifically, the categories helplessness, avoidance and wishful thinking were prognostically associated with increased general psychological distress. Approach-oriented coping was not associated with subsequent psychological distress. Conclusions: The prognostic value of coping strategies for later psychological distress in RA is weak. Limited evidence suggests that avoidant-oriented coping is associated with increased subsequent psychological distress. No evidence was found that approach-oriented coping protects against an increase of psychological distress.

The knee joint is the largest and one of the most complex joints in the human body. The Introduction describes the relevant anatomy and biomechanics of the knee. In addition, osteoarthritis was explained, followed by the total knee replacement (TKR) as treatment of choice. The two main surgical philosophies in TKR were introduced: the measured resection approach and the balanced gap technique. The balanced gap technique focuses on soft tissue management before bone cuts are performed. Several issues are related to this specific approach. The overall aim of this thesis was to investigate these issues; the effect of the balanced gap implantation technique on knee stability was investigated. Furthermore, technical issues such as releases, femoral component rotation, and balancing of the posterior cruciate ligament as well as the consequences of these techniques were addressed. The goal of Study 1 was to examine the relation between gap size and anterior translation of the flexion gap during implantation of a PCL-retaining total knee prosthesis. In 91 knees the flexion gap and anterior tibial translation were measured intraoperatively using a mono-block, custom-made, flexible tensorspacer device. The results showed that each mm increase in the flexion gap produced a correspondingly greater increase in the anterior tibial translation, on average a 1:1.25 (SD 0.79, CI95: 1.13-1.37) relation. When placing a PCL-retaining TKR, the surgeon needs to be aware of the consequences for the tibiofemoral contact point related to his/her choice for the thickness of the polyethylene insert: when the flexed knee is distracted with a force between 100 and 200 N, an additional 2 mm polyethylene would result in an average additional 2.5 mm anterior translation of the tibia. Because of the PCL's oblique orientation it is conceivable that flexion gap distraction could lead to anterior movement of the tibia relative to the femur. This tibiofemoral repositioning would influence the tibiofemoral contact point, which in turn would affect the kinematics of the TKR. Study 2 quantitatively describes the flexion gap parameters when during implantation of a PCL-retaining TKR, the knee is distracted using a bicompartmental tensor. Furthermore, the effect of PCL elevation (steep or flat) and collateral ligament releases on the flexion gap parameters were studied. During a ligament-guided TKR procedure, the flexion gap was distracted with a double-spring tensor with 200 N in 50 knees after the tibia had been cut. The flexion gap height, anterior tibial translation and femoral rotation were measured intra-operatively using a CT-free navigation system. During flexion gap distraction, the greatest displacement was seen in anterior-posterior direction. The mean ratio between gap height increase and tibial translation was 1:1.9, and was the highest for knees with a steep PCL (1:2.3). Knees with a flat PCL and knees with a ligament release had a larger increase in PCL elevation when the gap was distracted. When the PCL is tensioned, every extra mm that the flexion gap is distracted can be expected to move the tibia anteriorly by at least 1.7 mm (flat PCL), or even more if there is a steep PCL. The surgeon must not ignore this as it has consequences for the tibiofemoral contact point and polyethylene wear. In order to determine how "tight" a total knee prosthesis should be implanted, it is important to know the amount of laxity in a healthy knee. The objective of Study 3 was to determine knee laxity in extension and flexion in healthy, nonarthritic knees of subjects similar in age to patients undergoing a TKR and thus, to provide guidelines for the orthopaedic surgeon to restore the stability of an osteoarthritic knee to the normal condition. Thirty healthy subjects were included in this study. For each subject one, randomly selected, knee was stressed in extension and in 70° flexion (15 Nm). Varus and valgus laxity in extension and flexion were measured on radiographs. The passive range of motion and active flexion angle were assessed. Mean valgus laxity in extension was 2.3° (SD 0.9, range 0.2-4.1°). In extension mean varus laxity was 2.8° (SD 1.3, range 0.6-5.4°). In flexion, mean valgus laxity was 2.5° (SD 1.5, range 0.0-6.0°) and mean varus laxity was 3.1° (SD 2.0, range 0.1-7.0°). Varus and valgus knee laxity in extension and in flexion were comparable. The results in this study showed that the normal knee in this age group has an inherent degree of varus-valgus laxity. Whether the results of the present study can be used to optimise the TKR implantation technique requires further investigation. The prospective Study 4 investigated whether ligament releases necessary during TKR lead to a higher varus-valgus laxity during intra-operative examination after implantation of the prosthesis and after 6 months. The laxity values of TKR patients were also compared to healthy controls. Varus-valgus laxity was assessed intra- and postoperatively in extension and 70° flexion in 49 patients undergoing TKR, using a balanced gap technique. Knees were catalogued according to ligament releases performed during surgery. Postoperative varus-valgus laxity and laxity after 6 months had not increased following release of the posteromedial capsule, iliotibial tract, and the superficial medial collateral ligament. The obtained postoperative laxity compared well with the healthy equally-aged control group. It can be concluded that the balanced gap technique results in stable knees and that releases can safely be performed to achieve neutral leg alignment without causing postoperative laxity. Ligament releases can be performed to achieve restoration of mechanical alignment after TKR. Several previously described sequences and results achieved on cadaver knees with measured resection implantation techniques are not be applied to the balanced gap technique. In Study 5 the peroperative effect of stepwise, soft tissue releases following the "tightest structure first" on leg axis in extension and femur rotation in flexion was investigated. During PCL-retaining TKR using a balanced gap technique in 54 patients, we determined the effect of each ligament release using a navigation system while the knee was distracted with a tensor in extension and flexion. The effect on alignment in extension and on femoral rotation in flexion was measured separately after each release. In more than half of the patients, one or more ligament releases were necessary. Release of the posteromedial condyle led to a minor effect on leg axis in extension and femoral rotation in flexion; release of the superficial medial collateral ligament, to a few degrees, mainly in extension. Release of the iliotibial tract led to a small correction of leg alignment in extension. There was no statistically significant difference in the alignment-correcting effect of a release dependent upon the sequence in which the structure was released. In PCLretaining TKR a step-wise "tightest structure first" protocol for ligament releases in extension with the balanced gap technique results in an effective, gradual, alignment correction in extension, and limited femoral rotation effects in flexion. The most specific characteristic of the balanced gap implantation technique is that, within the restrictions produced by soft tissue structures, femoral component rotation can vary freely. Since internal rotation might cause patella problems, the effect of ligament releases on femoral component rotation was prospectively assessed in Study 6. Femoral component rotation was measured intra-operatively with a tensor applied in flexion at 150 N in 87 knees. A great interpatient variability was found; femoral component rotation, referenced from the posterior condyles, ranged from -4° to 13°. There was no difference in femoral component rotation between knees with or without ligament releases in extension. However, knees with major medial releases had less external femoral component rotation than knees with minor lateral releases. Pre-operative alignment had no influence on femoral component rotation. Theoretically, the use of the balanced gap implantation technique will result in a balanced flexion gap, but the amount of femoral component rotation will be variable as a result of patient variability and variation in ligament releases. Whether this has consequences for patellar tracking needs to be investigated. Patella position can be measured on axial radiographs and many measurement techniques have been described in the literature. Study 7 evaluates the inter- and intra-observer reproducibility of suitable measurement techniques for patients with a knee prosthesis found in the literature. Fifty axial patella radiographs from knee prostheses were used to measure the reproducibility of five measurement techniques. Reproducibility was calculated using the Bland and Altman method. Lateral Patellar Tilt (>10°) and Patellar Displacement (≥4mm) methods were found to be the most reproducible methods to measure patellar tilt or displacement, respectively. The goal of Study 8 was to investigate whether femoral component rotation influenced patella position after a primary total knee replacement with the balanced gap technique. In this prospective cohort study, a primary TKR was implanted in 49 patients using a balanced gap technique and a CT-free navigation system. Femoral component rotation referenced from the posterior condyles was measured using the navigation data of the distal femur cut. At the 2-year follow up, lateral patellar tilt and patellar displacement were measured on axial patella radiographs. Logistic regression analysis on femoral component rotation and pre-operative patella position was conducted to identify predictors for postoperative patellar tilt and displacement. Copyright © Informa Healthcare Ltd 2011.

Biemond J.E.,Sint Maartenskliniek | Venkatesan S.,Sint Maartenskliniek | Van Hellemondt G.G.,Sint Maartenskliniek
Bone and Joint Journal | Year: 2015

The long-term survival of the cementless Spotorno CLS femoral component in patients aged > 50 years at the time of arthroplasty was investigated. Survivorship analysis of a consecutive series of 85 patients (100 hips; under 50 years of age at a mean follow-up of 18.4 years (16.3 to 20.8)) was performed. The clinical and radiographic outcomes were satisfactory. The overall rate of survival of the femoral component was 93.5% (95% confidence interval (CI), 90.9 to 96.1) after 19 years. Survival with revision for aseptic loosening as the end point was 95.7% (95% CI 93.6 to 97.8%) at 19 years. This study demonstrates an excellent long-term survival of the Spotorno CLS femoral component after 16 to 20 years in young patients undergoing total hip arthroplasty. ©2015 The British Editorial Society of Bone & Joint Surgery.

Schimmel J.J.P.,Sint Maartenskliniek | Walschot L.H.B.,Sint Maartenskliniek | Louwerens J.W.K.,Sint Maartenskliniek
Foot and Ankle International | Year: 2014

Background: Total ankle replacement (TAR) is presently considered to be an acceptable alternative to ankle fusion for patients with debilitating conditions of the ankle. The placing of a total ankle prosthesis is a technically demanding procedure. We hypothesized that the challenging conditions could cause a longer learning curve (>30 cases), and therefore the short-term results of the first and the last 50 cases in a consecutive series of 134 cases were compared. Methods: The first and last consecutive 50 cases by a single surgeon in a series of 134 Scandinavian Total Ankle Replacements (STAR; Waldemar Link, Hamburg, Germany), inserted between May 1999 and May 2008, were evaluated. Operation characteristics, clinical outcome (Foot Function Index [FFI], Kofoed score), complications, and the component alignment on X-rays were assessed. The outcome measures for both groups were compared using independent Student t tests, chi-square tests, and nonparametric alternatives (P < .05). Results: Surgery time decreased from a median of 125 (83-160) to 100 (65-170) minutes (P < .001), and fewer perioperative complications were observed (12 vs 4, P = .04). The sagittal alignment of the tibial component was closer to normal in the last series (P < .001). The clinical outcome did not differ between the 2 series (median FFI: 32 [0-74] vs 25 [0-75], Kofoed score: median 71 [21-96] vs 80.5 [23-100]). The major underlying pathology did change from rheumatoid arthritis (60%) to osteoarthritis (44%; P = .002). No differences in type and number of complications were reported. Conclusion: The surgery time did decrease, there were fewer perioperative fractures, and the tibial component orientation improved, suggesting the presence of a learning curve. Operative experience and a shift in major underlying pathology did not influence clinical outcome. In view of this learning curve we suggest more restrictive patient selection for at least the first 50 TARs. © The Author(s) 2014.

In the Netherlands the current, conservative management of osteoarthritis of the hip and knee is heterogeneous and suboptimal. Existing guidelines only provide indications for certain interventions, but they do not provide recommendations about the sequence of these treatments. A step-by-step treatment strategy has now been developed in addition to the guidelines. Its aim is to optimize and clarify the conservative policy for osteoarthritis. In addition, communication between patients and professionals and between professionals themselves must be encouraged. According to the treatment strategy, relatively advanced interventions are considered only after simpler interventions have had insufficient results. A care booklet has also been developed that contains information for patients about osteoarthritis, treatment options, healthcare professionals and the treatment strategy.

Sanders R.J.M.,Sint Maartenskliniek | Swierstra B.A.,Sint Maartenskliniek | Goosen J.H.M.,Sint Maartenskliniek
Archives of Orthopaedic and Trauma Surgery | Year: 2013

Introduction: Total hip arthroplasty (THA) is one of the treatment options in patients with cerebral palsy (CP) with painful osteoarthritis of the hip. However, the risk of dislocation of the prosthesis is higher in patients with CP when compared with physically normal patients. In this retrospective study of ten consecutive cases, we hypothesized that the use of a dual-mobility cup could reduce this risk of dislocation combined with good functional results. Materials and methods: From January 2008 until October 2010, eight patients (ten hips) with CP who consecutively received a THA using a dual-mobility cup were identified. At the time of surgery, the average age of the patient group was 54 years (range 43-61). Latest follow-up took place after on average 39 months (range 22-56 months). All patients or their caregivers were interviewed by telephone. They were asked if dislocation of the prosthesis had occurred. To evaluate quality of life and health in general, patients completed the SF-36 questionnaire. Results: None of the prostheses had dislocated at the latest follow-up. Reoperation was needed in one patient after a periprosthetic fracture. Radiologic evaluation showed a mean cup inclination of 46 (range 27-58). On average, the quality of life of patients in this study was found to be limited in particular on the domains of physical health and functioning, while a fair to good score was measured at the six other different domains. Conclusion: The use of a dual-mobility cup in THA in patients with CP can lead to favourable results with respect to dislocation and clinical outcome. © 2013 Springer-Verlag Berlin Heidelberg.

Wagener M.L.,Sint Maartenskliniek | Beumer A.,Sint Maartenskliniek | Swierstra B.A.,Sint Maartenskliniek
BMC Musculoskeletal Disorders | Year: 2011

Background: The arthroscopic findings in patients with chronic anterior syndesmotic instability that need reconstructive surgery have never been described extensively. Methods. In 12 patients the clinical suspicion of chronic instability of the syndesmosis was confirmed during arthroscopy of the ankle. All findings during the arthroscopy were scored. Anatomical reconstruction of the anterior tibiofibular syndesmosis was performed in all patients. The AOFAS score was assessed to evaluate the result of the reconstruction. At an average of 43 months after the reconstruction all patients were seen for follow-up. Results: The syndesmosis being easily accessible for the 3 mm transverse end of probe which could be rotated around its longitudinal axis in all cases during arthroscopy of the ankle joint, confirmed the diagnosis. Cartilage damage was seen in 8 ankles, of which in 7 patients the damage was situated at the medial side of the ankle joint. The intraarticular part of anterior tibiofibular ligament was visibly damaged in 5 patients. Synovitis was seen in all but one ankle joint. After surgical reconstruction the AOFAS score improved from an average of 72 pre-operatively to 92 post-operatively. Conclusions: To confirm the clinical suspicion, the final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle. Cartilage damage to the medial side of the tibiotalar joint is often seen and might be the result of syndesmotic instability. Good results are achieved by anatomic reconstruction of the anterior syndesmosis, and all patients in this study would undergo the surgery again if necessary. © 2011 Wagener et al; licensee BioMed Central Ltd.

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